Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) Training Manual: Effective 4/01/04

Summary of the revisions specified in the “IRF-PAI Training Manual: Effective 4/01/04.” The “IRF-PAI Training Manual: Effective 4/01/04” is the version of the manual that must be used when assessing Medicare Part A fee-for-service patients who are admitted on or after April 1, 2004, and when recording that assessment data on the IRF-PAI. Overview The IRF-PAI manual has been revised in order to clarify how to complete the IRF-PAI assessment form, and to make technical ICD-9-CM coding and clerical changes. If a Medicare Part A fee-for-service patients is admitted to an IRF on or after April 1, 2004, an IRF must use the “IRF-PAI Training Manual: Effective 4/01/04” as guidance when performing the IRF-PAI assessment process and recording the assessment data. We believe that making the use of this manual mandatory on April 1, 2004, allows sufficient time for IRFs to educate their staffs regarding the changes specified in the 4/01/04 version of the manual, helping to ensure that the staff of IRFs are using the same manual when performing an IRF-PAI assessment and recording the IRF-PAI data. The changes specified in the “IRF-PAI Training Manual: Effective 4/01/04” are detailed below in the section entitled “Changes made to the IRF-PAI manual.” The most significant change specified in this revised version of the manual is the change made to the scoring of the Function Modifiers and FIMTM items during the discharge assessment. This revised manual specifies that during the discharge assessment MOST of the data recorded in the Function Modifiers and FIMTM items should reflect the lowest functional score within any 24-hour period that is within the three-calendar day discharge assessment time period. In order to more accurately code a patient’s etiologic diagnosis technical coding changes were made to Appendix B of the manual. Many of the changes made to the manual were clerical. For example, because during 2002 the Internet address for the IRF PPS website changed we had to change the Internet address that appeared in the previous version of the manual. The current IRF PPS web site is http://www.cms.hhs.gov/InpatientRehabFacPPS/. Please note that we are not referring to this current version of the manual as a "final" manual. The CMS anticipates that the IRF PPS policies will continue to be refined. Consequently, the IRF-PAI Training Manual may have to be periodically revised. The information contained in the IRF-PAI Training Manual describes the IRF-PAI assessment process. However, because there is a long time interval between manual updates, during the time interval between manual updates CMS will continue to post information regarding the IRF PPS, including the most current information regarding the IRF-PAI assessment process, on the IRF PPS website. For questions regarding how to code an item on the IRF-PAI assessment form first call the IRF-PAI help line at (866) 216-8089. If you have an IRF PPS policy question, or if the IRF-PAI help line is unable to answer your question, contact one of the CMS staff members identified on the first or second page of an IRF-PPS Final Rule. In order to assist you to identify the changes specified in this revision of the manual, below CMS has referenced by page and section the changes that were incorporated into the “IRF-PAI Training Manual: Effective 4/01/04.”

IRF-PAI Training Manual: Effective 4/01/04 (PDF File; 1,292 kb)

Changes made to the IRF-PAI manual:

• Revision date has been changed on all pages to "Effective 4/01/04".

• Copyright statement at bottom of all pages was revised to show "copyright (c) 2001 - 2004".

• Page ii of the Table of Contents was changed to reflect changes in page numbers of various portions within Sections II and III.

• Page 2 of Section I has been changed to include the following text: Note: The rule governing the types of medical conditions and percent of the inpatient rehabilitation population that must meet these conditions is currently under CMS review. Therefore, this list of medical conditions will probably change or may already have been changed. Facilities are urged to check the following website for updates on this regulation: http://www.cms.hhs.gov/InpatientRehabFacPPS/

• The reference to the IRF-PAI on Page 4 of Section I was changed and the following is the revised text: The paper or electronic version of the patient assessment instrument illustrated in Appendix E (IRF-PAI) is the instrument that must be used to collect patient assessment data, which the software in the electronic version of the IRF-PAI will use to classify a patient into a CMG. The CMG determines the amount an IRF may be paid for the services it furnished to a Medicare Part A fee-for-service inpatient.

• Page 4 of Section I indicates that the IRF PPS web site now is: "http://www.cms.hhs.gov/InpatientRehabFacPPS/".

• A subheading was added to Page 1 of Section II to clarify how the items are completed for short stay patients.

• Page 1 of Section II contains a new sentence indicating that at discharge facilities "must complete all of the function modifiers and FIM instrument items."

• Page 1 of Section II has been revised to show that "codes of 0 may be used if necessary for certain Function Modifiers"

• Pages 2 through 4 of Section II clarify the admission and discharge assessment schedules.

• Pages 9 - 10 of Section II indicate how item 20 “Payment Source” must be coded in order for an IRF to be able to transmit the IRF-PAI data to CMS. These changes were implemented in October 2002, and CMS posted the changes on the IRF PPS website prior to their implementation.

• Page 10 of Section II has been modified to indicate that "An IRF may, but is not required to, transmit an IRF-PAI data record if the payer is Medicare MCO."

• Page 10 of Section II indicates that the IRF PPS web site for Frequently Asked Questions now is: "http://questions.cms.hhs.gov".

• Page 10 of Section II has been modified to show that CHAMPUS is now known as TRICARE.

• The paragraph on Page 14 of Section II that begins with the word “Note:” was changed to reflect the correct alignment of the training manual with Chart 5 from the August 7, 2001 Final Rule.

• Pages 22 and 23 of Section II specify that level of assistance and distance must be considered when scoring item 37 “Walk” and item 38 “Wheelchair.”

• Pages 23 and 24 of Section II clarify the recording of the discharge assessment reference date and its relationship to the calculation of the patient’s length-of-stay.

• Page 25 of Section II indicates that the IRF PPS web site now is: "http://www.cms.hhs.gov/InpatientRehabFacPPS/".

• Page 27 of Section II has a reference to the claim instead of using the text “UB-92.”

• Page 3 of Section III, first paragraph, has been revised to show indicate that "the score range is a minimum of 1 and a maximum of 7, except for Items 35 and 36, where the maximum score is three (3) and for some Function Modifiers a code of 0 may be used."

• Beginning with item 2, pages 3 and 4 of Section III were modified to reflect a change in how the FIMTM instrument and Function Modifier items on the discharge IRF-PAI are to be collected. With the exception of items reflecting bladder and bowel function, the IRF-PAI FIM instrument items and the Function Modifiers should reflect the lowest functional score within any 24-hour period within the three calendar days comprising the discharge assessment. Bladder and bowel items are exceptions since assessing level of assistance for these items requires a 3-day look-back period and assessing frequency of accidents for these items requires a 7-day look-back period.

• Page 5 of Section III, item 4, has been modified to indicate "not what the patient should be able to do, not a simulation of the activity, or not what they are expected to do in a different environment (e.g., home)."

• Page 5 of Section III has been modified: The note related to Items 39N and 39O has been made into its own paragraph.

• Pages 17 - 18 of Section III, Comment, have been modified to read, "When assessing dressing and undressing, the subject must use clothing that is appropriate to wear in public. If the subject wears only hospital gowns or nightgowns/pajamas, rate this activity as code 0. Starting at the time that

the patient is admitted to the IRF and continuing during the admission assessment time period the IRF's staff must make every attempt to obtain from any source clothing for the patient. For example, if a patient is admitted wearing a hospital gown and without, not possessing, any other items of clothing, then the staff of the IRF should immediately request that the patient's family or friends bring as soon as possible to the patient clothing suitable for the patient to wear which would cover the patient's upper body and lower body including footwear. Once clothing during the admission assessment time period is available, then any previous scoring during the admission assessment time period should be updated to reflect the performance of this task with clothing. The task of dressing should be scored during what is the usual time of the day that the patient is awake and alert. The result would be that the updated score would be more reflective of the patient's actual functional performance which is not the case when a score of "0" is used, because a "0" score only indicates that the activity did not occur during the admission assessment time period."

• Pages 20 - 21 of Section III, Comment, have been modified in the same manner as listed above for page 17 - 18 of Section III.

• Pages 25 and 29 of Section III reflect that the sentence "The patient has no accidents" has been removed from scoring Level 6.

• Pages 25, 27, 29, and 31 of Section III, level 6, have been modified to indicate use of a bedside commode.

• Page 35 of Section III, first line, has been modified to indicate "safely getting on and off a standard toilet."

• Pages 37 and 39 of Section III, below level 1, have been modified to insert the Function Modifier item numbers (Item 33, Item 34).

• Page 1 of Appendix A was revised to correct a typographical error. Specifically, Spinal Cord Dysfunction Impairment Group Codes 04.110 - 04.130 were correctly labeled as "Non-Traumatic" and Impairment Group Codes 04.210 - 04.230 were correctly labeled as "Traumatic".

• Page 3 of Appendix A was revised to correct a typographical error. Specifically, the description of the Debility group was revised to reflect "Non-cardiac, Non-pulmonary".

• A number of changes meant to clarify how the etiologic diagnosis should be coded were made to Appendix B as follows:

o Page B - 1: The description of the late effect codes 438.0 - 438.9 has been revised.

o Page B - 2: Code 215.0 has been deleted.

o Page B - 2: Code 239.7 has been deleted. Code 239.6 has been added.

o Page B - 3: Two late effects codes, 905.0 and 907.0 have been added.

o Page B - 4: Two late effects codes, 905.0 and 907.0 have been added.

o Page B - 6: Code 907.2 (late effect of traumatic spinal cord injury) has been deleted.

o Page B - 6: Has been revised to correct a typographical error. It now reads: "whether non-traumatic (i.e., medical or post-operative - codes 4.110 - 4.130), or traumatic (-codes 4.210 - 4.230)"

o Page B - 6: The note concerning Spinal Cord Dysfunction has been revised. It now reads: "Cases for which the impairment requiring rehabilitation can be definitively linked to a prior spinal cord dysfunction should be coded as spinal cord dysfunction"

o Page B - 7: The description of late effect code 907.2 has been revised. The note indicating when amputation should be coded has been removed.

o Page B - 8: Codes 250.6 - 250.63, 250.7 - 250.73, 250.8 - 250.83, 356.0 - 356.9, 357, 444.22, 447.3, and 447.4 have been deleted. The description for code 443.81 has been revised. Codes 730.0x - 730.3x have been added. Code 733.4x has been revised to 733.40, 733.41, and 733.49.

o Page B - 9: Codes 785.4 and 443.81 have been added. The description for codes 357.0 - 357.9 has been revised. Codes 444.21, 447.3 and 447.4 have been deleted. Code 707.1 has been revised to 707.1x.

o Page B - 10: Codes 730.05 - 730.07, 730.15 - 730.17, 730.25 - 730.27, 733.40, 733.42 - 733.49, and 785.4 have been added. Codes 747.63, V 52.0, V 52.1, and V 57.81 have been deleted.

o Page B - 11: Code 701.0 has been deleted.

o Page B - 14: Code 414.00 - 414.05 has been revised to 414.00 - 414.07. Codes 715.00 - 715.99 have been revised to 715.x5 – 715.x6. Codes 716.00 – 716.99 have been revised to 716.x5 – 716.x6.

o Page B - 15: Code 518.5 has been deleted. Code 492.00 has been revised to 492.0. Codes 944.0 - 944.59 have been revised to 944.00 - 944.58. Codes 946.00 - 946.59 have been revised to 946.0 - 946.5.

o Page B - 17: The words "trauma" and "complex" have been capitalized to indicate that major multiple trauma cases are those in which trauma was the cause of the injury and that the resulting problems are complex as opposed to routine.

o Page B - 17: A note has been added indicating that if only multiple fractures are present, the impairment group should be coded 08.4 Major Multiple Fractures.

o Page B - 18: Instructions to code the specific medical condition responsible for the debility have been added.

o Page B - 20: Codes 175.0 - 175.9 have been added.

o Page B - 21: Codes 403.99 - 403.93 have been revised to 403.00 - 403.91. Codes 414.00 - 414.05 have been revised to 414.00 - 414.07.

o Page B - 22: Codes 681.11 - 681.12 have been revised to Codes 681.10 - 681.11. Codes 682.2 - 682.8 have been revised to Codes

682.0 - 682.8. Codes 870.0 - 870.9 have been revised to Codes 870.0 - 879.9.

• Pages 1 and 2 of Appendix C clarify the coding of comorbid conditions, particularly the use of ICD-9-CM categories and ICD-9-CM codes.

• Page 2 of Appendix C updates the ICD-9-CM codes of the comorbid conditions listed in the Appendix C table.

• Pages 3 through 31 of Appendix C were revised to reflect the appropriate letter code for the Tiers, as well as to include the updated comorbid conditions in the table.

• Page 8 of Appendix D was revised to correct a typographical error. As a result of this correction, Appendix D now has 13 rather than 14 pages.

• The IRF-PAI form in Appendix E was updated to specify the most current OMB Clearance date, which is: "OMB-0938-0842 (expires: 07-31-2005)".

• A reference to the updated 2004 payment rates was added to Appendix F

• Page 1 of Appendix I indicates that the IRF PPS web site now is: "http://www.cms.hhs.gov/InpatientRehabFacPPS/".

• Page 2 of Appendix J clarifies that for some CMGs the patient's admission cognitive score and/or age at admission help to define the CMG. In addition, this page indicates that the IRF PPS web site now is: "http://www.cms.hhs.gov/InpatientRehabFacPPS/".

• The table on pages 3 through 7 of Appendix J was revised to include the letter labels associated with the comorbidity tiers.

• Appendix K which describes a patient’s privacy and patient rights was updated. Two forms, which must be given to a Medicare inpatient before performing an assessment with the IRF-PAI, were added to Appendix K.

• Page 2 of Appendix K has been modified to show that the privacy forms are included on the following pages in Appendix K.

• Page 6 of Appendix K indicates that the IRF PPS web site now is: "http://www.cms.hhs.gov/InpatientRehabFacPPS/”